First Name: Middle Initial: Last Name: Sr, Jr III:
Phone (Home): Work: Cellphone:
Address: City: State: Zip:
Date of Birth: Month: Day: Year: Sex:
Place of Birth: City: State: Country: US Citizen
Race: Age: Height: Weight:
Driver's License Number: State:
High School: College or Technical School:
List ALL arrest below:
How long have you lived in the Charlotte-Mecklenburg County Area?
How long have you lived in North Carolina?
List your employment history for the last three years:
Do you currently, or have you ever, habitually used hard/illegal drugs or alcohol to excess?
If yes, please explain (dates addicted, treaded, cured, etc.):
Please list any other fraternal or commercial organizations or unions to which you belong, along with any offices held:
What prompts you to make this application?
List the names of three persons, not related to you and not former employers, who have known you for a period of at
least five years. Please include their address and phone number.
Are you familiar with the requirements and purpose of this organization and are you willing to execute your duties as a member?
I will abide by and support the Constitution and By-Laws of this order; I will not use the authority invested in me as a member
for personal gain, or for any other purpose, except for the best use, interest, and welfare of this lodge and its members.
I further understand that if any answers to the questions on this application are found to be false, I will not be accepted
for membership, or if already accepted I will be removed.
Should I violate this, my solemn oath or obligation, I hereby bind myself under no less a penalty than being expelled from
Date: Signature of Applicant:
the order. To all of which I solemnly and sincerely promise and swear, so help me God, and keep me steadfast.
I, , do hereby authorize the CHARLOTTE-MECKLENBURG FRATERNAL ORDER OF POLICE LODGE #9
to obtain any information regarding me in order that the membership committee may determine
my suitability for membership.
Signature of Applicant:
This section for sponsor only
Date: Sponsored by: